Prep for CIGNA Pre-Approval
"Unless excluded from the benefit plan, this service is covered when the following medical necessity criteria are met.
CIGNA HealthCare covers bariatric surgery using a covered procedure outlined below as medically necessary when ALL of the following criteria are met:
• The individual is ≥ 18 years of age or has reached full expected skeletal growth AND hasevidence of one of the following:
�� BMI (Body Mass Index) ≥ 40 for at least the previous 12 months.
�� BMI (Body Mass Index) 35–39.9 for at least the previous 12 months with at least oneclinically significant comorbidity, such as a serious cardiopulmonary problem, Type 2diabetes, hypertension, coronary artery disease, or pulmonary hypertension that has failed to respond adequately to appropriate medical management.
• Active participation within the last two years in one physician-directed weight-management program for a minimum of six months without significant gaps. The weight-management program must include monthly documentation of ALL of the following components:
�� Vital signs, including weight �� Current dietary program �� Physical activity (i.e., exercise program) �� Behavioral interventions to reinforce healthy eating and exercise habits �� Consideration of pharmacotherapy with U.S. Food and Drug Administration (FDA)-approved weight-loss drugs, if appropriate
For individuals with lifelong, morbid obesity, participation in a program within the last five years is sufficient if documentation of six months is available and reasonable compliance with the weight management program over an extended period of time can be demonstrated. However, diet programs/plans alone, such as Weigh****chers®, Jenny Craig® and similar plans, are not considered physician-directed weight-management programs and do not meet this requirement.Similarly, physician-directed programs consisting exclusively of pharmacological management are not sufficient to meet this requirement. • Recent evaluation by a multidisciplinary team including: �� A thorough medical history and physical examination. �� An evaluation by a licensed mental health care professional that specifically addresses any mental health or substance abuse diagnoses, the emotional readiness and ability of the patient to make and sustain lifestyle changes, and the adequacy of their support system. If an individual is already in behavioral health treatment, consultation with theirtreating clinicians should also be sought. �� A thorough nutritional evaluation by a physician or registered dietician experienced in the issues of bariatric surgery, who has had a meaningful conversation with the individual regarding the dietary and lifestyle changes required to ensure a successful outcome over time.
When the specific medical necessity criteria noted above for bariatric surgery have been met, CIGNA HealthCare covers ANY of the following bariatric surgery procedures: • vertical banded gastroplasty • Roux-en-Y gastric bypass • adjustable silicone gastric banding (e.g., LAP-BAND®) CIGNA HealthCare covers adjustment of a silicone gastric banding as medically necessary to control the rate of weight loss and/or treat symptoms secondary to gastric restriction following a medically necessary adjustable silicone gastric banding procedure. CIGNA HealthCare does not cover the following bariatric surgery procedures, because they are considered experimental, investigational or unproven (this list may not be all-inclusive): • biliopancreatic diversion with duodenal switch (BPD/DS) • Fobi-Pouch (limiting proximal gastric pouch) • intragastric balloon • mini-gastric bypass • sleeve gastrectomy (SG)"
Excerp from CIGNA HealthCare Coverage Position, Subject: Bariatric Surgery, Revised 5/15/2007
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